By Joyce Reingold
Incisionless focused ultrasound. They are three words that when combined describe a potentially life-changing treatment for people who have tremor-dominant Parkinson’s disease or essential tremor.
Last year, Delray Medical Center became the first hospital in Palm Beach County to offer this procedure, which uses magnetic resonance imaging to direct high-intensity ultrasound at the brain tissue at the source of the tremor.
“Tears, joy, amazement,” says Dr. Lloyd Zucker, chief of neurosurgery at the medical center, describing patients’ reactions when they see their steady arms and hands at the end of the treatment. “I still stand in awe every single time we do it.”
Zucker has been performing the procedure for three years — most recently in his role at Delray Medical Center, which is part of Tenet Healthcare. It’s done using the Exablate Neuro device, which was developed by Insightec.
The U.S. Food & Drug Administration approved the use of the Insightec device in 2016 for essential tremor and in 2018 for Parkinson’s disease.
While it’s not a treatment option for every patient with motor symptoms, it’s a life-changing addition to the options already available.
“For many years, medication was the mainstay of treatment. … If you look at patients with essential tremor, many of them have tried one of three different medications. Fifty to 70% of them fail on medication treatment in five to seven years,” Zucker says.
“In the ’80s … there was the advent of something called deep brain stimulation, which is kind of what it sounds like. You put an electrode within the brain, you lead a wire under the scalp behind the ear and you put a pacemaker-like device by the clavicle.
“This delivers electrical impulses to the area of the brain that you’ve targeted and can be used for the tremors of essential tremor. And it can be used for the tremors of Parkinson’s disease and some of the other aspects like rigidity and slowness of motion. But there’s been a large number of patients that have been reluctant to undergo an intervention as great as that.”
The focused ultrasound is an outpatient procedure. Most patients go home the same day and return to their regular activities within a few days. Zucker explains how it works:
“Ultrasound is usually a very benign form of energy and we use it for many things. But now what we’ve done is we’ve combined a helmet with 1,000 ultrasound sources that are focused at a point. And when you focus all that ultrasound at a point, it generates heat. That in and of itself wouldn’t be enough, but we’ve used the MRI to help us target where we want to access within the brain.
“The end result of that is without an incision, without a hole, it basically works directly through the skull without ever having opened it,” he says.
Zucker says the ultrasound frequency is ablative, “which means it destroys a small area of the brain by using heat. So, we are using that to knock out an area that’s causing the symptom that we would like to see relieved or at least abated.”
The patient experience
In preparation for treatment, patients receive a local anesthetic so the special frame can be put on their heads. This holds heads still in the MRI.
“The patient is usually lying there anywhere from as short as an hour and a half to as long as about three hours. The actual treatments are ranging from 10 and 12 seconds to up to about 35 seconds. In between the treatments, the machine is actually going through a cooling phase. What makes it a longer day than just three 12-second treatments is that in-between time,” Zucker says.
Patients are evaluated during treatment intervals. “And when we’re satisfied that we’ve gotten reasonably good control or elimination of the tremor, we get them off the table and they go home,” he says.
Studies show tremor control in patients who had the procedure seven to 10 years ago, Zucker says. “It’s been studied a little longer in Europe. Obviously, the experience in the United States is a little bit shorter, but it appears to be a fairly robust and long-lasting therapy.”
Possible side effects
Medical interventions have their risks, of course. In Insightec-sponsored clinical studies, the most common adverse events associated with the MR-guided focused ultrasound were imbalance/gait disturbance (26% of study patients), numbness/tingling (33%) and headache/head pain (51%).
“Most of these events were classified as mild or moderate, and 48% of all adverse events resolved on their own within 30 days,” Insightec says on its website. (Learn more at www.insightec.com/safety-information.)
During the treatment, Zucker says some patients describe a feeling of warmth. Others have described feeling pressure, “and a few, extreme pressure.”
“Some patients have no discomfort at all. Some patients have mild to moderate discomfort. But nobody has gotten off the table with their tremor gone and complained about what they went through.”
‘It’s like I was born again’
South Floridian Carol Klein, one of Zucker’s patients, first felt disbelief, wonderment and then teary-eyed after treatment. A video on the Insightec Facebook page shows Klein, at procedure’s end, holding out a steady arm, the severe hand shaking from essential tremor gone.
“I have my old life back, and I thought it was gone. I did. It’s like I was born again,” she says in the video. Watch the video at www.facebook.com/INSIGHTEC.MRgFUS/videos/643328180376267/.
“Anybody that sees one of these surgeries, sees the patient before, sees the patient afterward, knows that it is life-changing. And when you get to do that, that’s kind of why I went into medicine in the first place,” Zucker says.
Joyce Reingold writes about health and healthy living. Send column ideas to firstname.lastname@example.org.